Mental Health Collaboration Hub
Patient presented from home where he lives with his mother. Patient was in residential treatment and group home from June 2022 until February 2025.
Patient has had several ER visits for aggressive behavior towards mother since returning home in February. Patient’s behaviors at home target his mother. He has engaged in eloping from home, stealing from neighbors in the apartment complex. Patient’s mother is struggling with her own mental health as a result of patient’s behaviors and does not feel safe with patient returning home.
Ancillary Support Service: CADI Case Manager
A CADI case manager is a professional who works with people with disabilities to help them live as independently as possible in community settings. They are responsible for assessing patient needs, evaluating treatment options, creating treatment plans, coordinating care, and gauging progress. They often work with physicians, social workers, families, and human services providers1. The Community Access for Disability Inclusion (CADI) Waiver is a program that provides home and community-based services to children and adults with disabilities who require the level of care provided in a nursing facility. These services are an alternative to institutionalization and promote optimal health, independence, safety, and community integration.
PH-F15-5890
Presented to ED after a verbal altercation with mother and expressed a suicidal plan to walk into traffic. History of cutting, scratching, elopement behaviors.
PH-F15-5562
Patient is a 15-year-old female, currently at PrairieCare Inpatient Hospital.
Recommendation is for level 6 PRTF.
Patient has had five previous inpatient hospitalizations through Abbott Northwestern and PrairieCare since April of 2022. Patient has had two admissions to PrairieCare partial hospitalization programming, and one admission to Anthony Louis Center RTC.
Establish PRTF:
-Nexus East Bethel (CMHCM sent referral, PC also sent a referral, declined for admission 04/16 due to believing PT needs a higher level of care- CABHH)
-Northwoods (Not a viable option due to insurance and 2 year waitlist)
-Grafton (Not a viable option due to patient not meeting admission criteria)
-Leo Hoffmann Center (Not a viable option due to patient not meeting admission criteria- only accept biological males)
MHF-F14-4898
Pt came to us 11/18/24 after an altercation at her ongoing GH in which she physically aggressed against another youth. Its reported that youth plans to press charges. She is not allowed to return to that GH, but that provider is working to see if they can set up a new setting for this pt, both temporary and ongoing. Team also has another GH they are looking into for her. This kiddo boarded with us previously, prior to discharge to her last GH, 9/24-11/1 of last year. Dakota County currently has custody. She is also open to CMH and waiver.
PH-M16-5290
Patient is a 16 yo male with history of DMDD, ADHD, GAD, and MDD. Patient has a history of at least 8 inpatient hospitalizations in the past seven years and has also participated in multiple outpatient programs. Stressors include family conflict, housing insecurity, and school.
MFIUP-F14-5242
Presented to ED for verbal agitation, physical aggression, significant behavior chance, suicidal ideation. Patient has also been engaging in SIB. Aggression has been ongoing for over a year and has intensified. Aggression comes on suddenly/does not seem to be predictable. Mom feels she has no control. Has an IEP for low IQ and learning difficulties. Refuses medications. Strained relationships with mother, father, and older siblings. Patient reports not having many close friends. Has engaged in lots of community and outpatient treatment options including individual therapy, family therapy, case management, school counseling, child protection, primary care, psychiatric medication management, day treatment. Has been hospitalized before at PrairieCare.
CH-F17-5216
Presents from home. Patient is known to our facility having previously boarded. Patient lives with aunt and uncle. There are issues with their relationship, and it has been increasingly difficult for aunt and uncle to manage, and they do not want patient to return home.
CH-M13-5196
Patient presented to the ER after an unprovoked stabbing of a sibling in the middle of the night requiring emergency surgery and then proceeded outside in the cold without weather appropriate clothing. Patient has chronic aggressive behaviors towards caretakers and other children.
CH-F11-5026
Pt presented from home, adopted parents, for aggressive behaviors. Third ER visit this month, unable to take pt back home due to frequency and intensity of behaviors as well as 4 other children in the home. Pt initially recommended IP hospitalization, however unable to find placement due to acuity, no beds, or declined due to IQ (56) and inability to participate in programming. Medications adjusted in ER. No violence since medication increase. Family/CADI worker have been looking for more support for several years and pt seems to fall through the cracks due to IQ and aggression.
MHF-F14-5169
Kiddo boarded in our ED from 11/18/24-12/18/24 after being discharged from JEC Miller GH. JEC Miller took her into a temporary placement in an apartment setting while County worked toward another permanent placement. On 1/19/25 she returned to our ED after ingesting glass and was sent to our medical floor, where she is currently boarding. County team is looking into placement options- primarily crisis respite. On CADI. Working on Nexus YCT referral to assist with placement coordination.
